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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Wednesday, November 1, 2017

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger
advocated for contraception, and more than 50 years since the oral contraceptive
pill became available. The last two generations of women – and men – have never
known a world where there was no effective form of contraception. They probably
do not recall when even condoms, although “over the counter” (in that no
prescription was required) were stocked “behind the counter” and required
requesting them from the pharmacist often with (if you were young) a
disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including
even murder committed on unmarried women who got pregnant and were unable, of
course, to have access to abortion should be things of the past. They are,
horrifically documented in Dan Barry’s New
York Times piece “The
Lost Children of Tuam”. The film “The Magdalene
Sisters” shows the intolerable treatment of girls who may not have even
gotten pregnant but were, perhaps, just a little too familiar with boys. Both the
Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was
perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic
Church, but the treatment of women in England and the US were also inexcusably harsh.
The British drama “Call
the Midwife” tells the story of an unmarried teacher who gets pregnant in
the early 1960s and is fired from her job (morally unfit to care for
children!), tries to self-induce abortion with a coat hanger, and almost dies.
Finally, post-hysterectomy so that she will never be able to have children, she
is driven out of town. The most sympathetic characters in the show see it as
sad, but none indicate it is horrific, immoral, and inhuman. And this was
commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability
of contraception, not to mention whether it works. Amazingly, we are. Teresa Manning, appointed by President Trump in May
to be the director of the Office of Population Affairs, the main family
planning arm of the federal government, is not only
a former employee of two anti-abortion groups, but has expressed
skepticism of the effectiveness of contraception itself! Manning, a lawyer
and not a health professional (although this is not an excuse), is completely
wrong. The data is in. Contraception dramatically decreases unplanned pregnancy
(regardless of marital status). Time recently
ran an article accurately describing the science titled “No,
birth control doesn’t make you have riskier sex”. That is the truth, but in
fact, even if it is was associated with riskier sex for some people, that would
be no reason to restrict access to it. The more contraception is available, the
lower the rate of bad outcomes of virtually all kinds. It even, of course,
reduces the rate of abortion; in fact, the only two things ever to have been
shown to significantly reduce the rate of abortion are comprehensive and
accurate sex education and easy and cheap availability of contraception.
Indeed, the degree to which contraception is effective in decreasing the
incidence of unplanned and undesired pregnancy is directly related to the ease
of its availability, including financial availability. Unsurprisingly, reducing
the cost of and increasing the ease of access to contraception has the greatest
impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t
think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary”
come to mind as better adjectives) has reversed
the ACA’s requirements that employers and insurers provide contraception at no
cost to women. Politically, it is part of the administration’s efforts to
dismantle the ACA piece by piece, since they were unsuccessful in doing it as a
whole. Morally, it is an imposition of a minority’s religious values on the
rest of us, and is particularly ironic being spearheaded by Donald Trump. It
will cause great harm to individual women (and men) and to the society as a
whole. Arguments that the cost of contraception is “only” $50 a month may wash
with those in the middle class and up, but for poor women and teens, $50 a
month is a lot. The most effective methods of contraception, IUDs and implants
(collectively referred to as LARC, long-acting reversible contraception) may
have a lower amortized cost over the use period but a high upfront cost that is
unaffordable, without subsidies, for many women. (The reason, lack of cash on
hand, is the same one that leads many poor families, as described by Barbara
Ehrenreich in her wonderful and depressing book “Nickel and Dimed”, to live in expensive weekly motel rentals –
the overall cost may be more than an apartment, but the upfront cost, including
deposits, rent in advance, etc., is prohibitive for them.) The impact on the
teens who will be denied free access is described
movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps
will -- be on the economy. This is articulately addressed in a
column by Bryce Covert in the NY Times,October 29, 2017. The reasons start
with individual women, and the cost of purchasing birth control, money which
will not be available for them to spend on other goods – with more than 57
million women using contraception, in one year that is $1.3 billion. But the
larger impact is societal – women who cannot control their own reproduction,
who do not know when and if they will get pregnant – are in a poorer position
to contribute to the workforce and to the economy. Again, going back to the
history I address at the start of this piece, we know this empirically, not
just theoretically:

…
a raft of evidence has definitively found that when women gained greater access
to the pill in the late 1960s and early ’70s, they were able to delay marriage
and childbirth and invest in careers through education, job training and
staying in paid work….Legal access to the pill transformed the economy in that
era. It increased young women’s labor force participation by 7 percent….about a
third of the increase in how many women attained careers in fields like law and
business was due to birth control. Women with earlier access to the pill also
made 8 percent more than their peers, and the pill was responsible for about a
third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just
cynically pandering to his base, and probably much of that base depends upon
contraception, women directly but men just as much. Opposition to contraception
cannot be justified except by the small minority of religious purists (and of
course they are welcome to not use it); opposition to making contraception
easily and freely available is almost as bad, as it is completely
discriminatory. It is still, as Covert describes,

…still
playing the economic role that it did in the 1970s. About half of women who use
it say they do so to complete education or to get and keep a job. Contraception
is still increasing the share of women who get educated and get paid work,
particularly prestigious jobs.

Easy and affordable (affordable for all those who need to
use it, not just billionaires or even the upper middle class!) is not a “women’s
issue”, it is not a “special interest” issue. It is a core need for people. People
with the views of Teresa Manning should not be given center stage, and
certainly not given authority over contraception. We need to guarantee
permanent access to contraception for all, and for accurate sex education.

1 comment:

Not to mention that the widespread availability of contraception through organizations like planned parenthood over the past two decades has resulted in a dramatic drop in teen pregnancies and abortions. But teen pregnancies are still higher than national average in states where disparities are highest https://www.cdc.gov/teenpregnancy/about/alt-text/map-state-text.htm which are often states where Republicans control the legislature. Those communities need better education and fewer unwanted pregnancies if they are going to make it out of the spiral of poverty and unemployment that is affecting the American South.